Aesthetic Dermal Filler Injections for Facial Rejuvenation Donald Brideau, MD, MMM, FAAFP

ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated: •

Discussion of use of some fillers for facial rejuvenation in areas not necessarily FDA approved. Slides will indicate which areas are approved or not approved.

Donald Brideau, MD, MMM, FAAFP Chief Operating Officer and Chief Medical Officer, Inova Health System, Inova Mount Vernon Hospital, Alexandria, Virginia; Family Physician, Alexandria; Associate Clinical Professor, GWU Medical School; Course Director for “Administrative Medicine” GWU Med School Dr. Brideau is a graduate of George Washington University School of Medicine & Health Sciences, Washington, DC. He completed undergraduate studies at Georgetown University in Washington, DC, and a Master's degree in medical management at Carnegie Mellon University in Pittsburg, Pennsylvania. Dr. Brideau practices family medicine part-time in Alexandria, Virginia. He has been a teacher of American Academy of Family Physician courses for the past 15 years. Topics he has covered include tobacco cessation and cosmetic skin care treatments. Dr. Brideau hopes to see more family physicians performing cosmetic procedures in their practices, not only as an additional source of income and variety within their scope of practice, but also as an additional service to patients.

Learning Objectives 1.

Assemble plans to address requests for dermal fillers, particularly among patients who may want injections to reduce the signs of aging.

2.

Outline appropriate treatment modalities and duration of action required for dermal filler injections.

3.

Assess the costs involved in ordering and performing dermal filler injections.

4.

Assess the risks and benefits involved in performing dermal filler injections.

Why consider fillers in your practice? • Patients are seeking these procedures: – Top 2 non-surgical cosmetic procedures in 2014 were • Botulinum toxin injections (6.7 million procedures- up 3% compared to 2013) • Dermal Fillers (2.3 million procedures-up 7%)

• FPs are trained in minor surgical and dermatologic procedures • Many patients prefer their own physician if properly trained.

Soft Tissue Augmentation: Effects • Plumping of the skin in the dermal and subdermal layers • Eliminate static wrinkles – Use botulinum toxin to decrease dynamic wrinkles

• Temporarily rejuvenate the aesthetic appearance of the face

3 D’s of Aging • Deflation – Loss of muscle mass causing excess skin – Estimate 10 ml volume loss per decade

• Degredation – As we age, we produce less collagen and therefore less elasticity in the skin

• Descent – Gravity takes hold causing dropping – All 3 D’s increase the appearance of aging

Collagen • The building block to our dermis – 70-80% of the dermis is collagen

• Loss of collagen begins in mid-20’s to early 30’s – Decrease affected by smoking, genetics, sun exposure, and hormones

Filler Sources • •

•

•

Autogenic:

Derived from the patient dermis, fat, plasma, collagen, fibroblasts) Allogenic: Derived from another human cultured or cadaveric collagen or fascia) Xenogenic:Derived from animal or bacteria bovine collagen, hyaluronic acids from rooster comb or bacteria e.g., Juvederm, Restylane) Synthetic : Derived in the Lab: Calcium Hydroxylapatite Poly-L-Lactic Acid

Fillers commonly used • Based on their ease of use, length of duration, non-allergenic – Hyaluronic acid ( Restylane Products1, Juvederm Ultra2 and Ultra Plus2,Voluma2 ,Belotero3) – Calcium hydroxylapatite ( Radiesse3) – Poly-L-Lactic Acid ( Sculptra4) –

1=Medicis 2= Allergan 3= Merz 4= Valeant

Fillers You Probably Won’t Use • Mostly historical at this point – Bovine Collagen: My old presentation – Human Collagen

• Used by Plastic surgeons: – Fat Transfers

Hyaluronic Acid • • • • •

Major component of connective tissue Synthetic is identical to animal types Last 1-2 years Binds water at 1000x its own weight 3 Major Products in US – Juvaderm Ultra and Juvaderm Ultra Plus and VOLUMA by Allergan (makers of Botox) – Restylane Product Line (regular, Lyft and Silk) by Galderma (makers of Dysport) – Belotero by Merz (makers of Xeomin)

Collagen stimulators •

Poly-L-lactic Acid (Sculptera) – – – – – –

•

1999 Approved in Europe 2004 Approved in US for Fat loss for HIV 2009 Approved for cosmetic wrinkles Biocompatible Mixed in Office Side Effects: Lumpiness in 9%

Calcium hydroxylapatite (Radiesse) – – – – –

Looks like toothpaste, found in bone Injected into subcutaneous layer, not dermal Doesn’t calcify, not bone Absorbs H2O Allows collagen to regrow between the calcium hydroxylapatite molecules

Collagen stimulators • Calcium hydroxylapatite (Radiesse) – Biocompatible – found in bone but not bone – Absorbs H2O – Allows collagen to regrow between the calcium hydroxylapatite molecules – Typically last at least 12 to 18 months

Old Bovine Collagen • • • •

Made from cowhide Not used as much but it was standard Purified to make it non-immunogenic 3-5% of patients have allergies so must perform a 30 skin test • Superficial lines • Last 6-12 weeks

New Bovine Collagen • Technology has changed the life span in one product: Bellafill by Suneva Medical Inc. – 80% Bovine Collagen Gel with 20% Polymethylmethacrylate microspheres (used in Plexiglass and contact lenses), with lidocaine – Indicated in Nasolabial folds and for acne scarring. – Collagen results in immediate improvement then absorbed. – Microspheres stimulate firm matrix with lasting results up to 5 yrs – Used in all skin types. – Needs Skin testing 4 weeks prior – 4.1% develop lumps but typically resolve.

Overall Indications for Fillers • • • •

Fine Lines Furrows Volumizer Lips – ALL of above depend on the type of filler and MD experience to get the best effects

Clinical Uses: approved and not – – – – – – – – – – –

Nasolabial fold glabella folds (off label) tear trough( nasojugal groove) (off label) cheek bone augmentation (off label) peri-oral lines (off label) lip augmentation (On Label Restylane, Juvederm Ultra) marionette lines nasal bone augmentation (off label) sub mental crease (off label) prejowl sulcus (off label) Hand Rejuvenation ( Radiesse on label)

Contraindications • • • • •

Pregnancy Lactation Sensitivity to product Skin disease in area to be treated Abnormal clotting

Side Effects • Hypersensitivity for some products – Old collagen fillers • Granuloma • Erythema • Swelling • Pain and Tenderness • Itching • Bruising • Rash

Preparing the Patient • At consult – Set Appropriate Expectations !!!!! – Use before and after pictures of preferably your patients to show results as examples – Advise fine wrinkles may remain – Obtain Consent

Decreasing Pain • Topical Anesthetic • Products with Lidocaine already mixed • Use skinniest needle appropriate for viscousity • Advise will at least sting

TOPICAL ANESTHETICS • EMLA Cream (AstraZeneca) • Ela-MAX 4% (Ferndale) • Compounding pharmacies make preparations of BLT (Benzocaine, Tetracaine and Lidocaine) • Wash off prior to the procedure

Where do I inject? Skin Anatomy

Injection Guidelines For Products discussed in basic: Limited to upper and middle dermis (generally) If too shallow, may result in blanching of the skin or bluish color (Tindle Effect). Lumpy appearance. If too deep, reabsorbed faster, takes more product to reach effect but safer than too shallow

Approach Depends on Depth of wrinkles • For Fine lines – – – –

Approach: Shallow angle 10-15 deg Filler type: Less Viscous Superficial Papillary level Example: Peri-oral or orbital

• Moderate to Deep: – – – –

Approach: 30-45 degrees Filler type: thicker viscousity Into Mid Reticular level of Dermis Example: Nasolabial folds/Marionette Lines

Approach Depends on Depth of wrinkles • For Deep Rhytids lines – Approach: Shallow angle >= 45 deg – Filler type: Most Viscous – Deep Dermal or below – Example: Cheek/tear trough

How Do I Know I am at the Correct Depth?

• Thin fillers: Juvederm Ultra and Restylane in Mid Dermis • Thick fillers: Juvederm Ultra Plus, Perlane and in deep dermis • Radiesse and Sculptera into subcutaneous area.

Too Superficial This will result in uneven appearance

Too Deep, but OK More product will be required

Deep Dermis Injection Plane

Method of injection • Appropriate Needle selection. – Needle size is determined by filler viscosity. – Use the smallest bore needles possible allowing for viscosity – Withdraw while injecting to avoid cannulation of a vessel – Multiple thin lines better result than one to two thick lines

Injection Technique • • • • •

Threading Fanning Cross hatching Push Ahead Serial Punctation

Threading • Single line per Injection site • Inject filler as needle is withdrawn • Steady pressure and speed to prevent lumpiness – Ever caulk your tile in bathroom

Fanning • Multiple lines per injection • Inject filler as needle is withdrawn

Cross Hatching • Multiple lines per injection • Inject filler as needle is withdrawn • Similar to fanning but lines intersect

Serial Puncture • Injecting in series of individual close punctures • Inject filler into site creating filling effect • Smooth deposited filler by massaging

Consult to Follow Up • Patient History – Risk of bleeding, scar formation – History of HSV • Need to pre and post treat with antivirals

– – – –

Prior treatmentsExamination with setting expectation Allergies to meds, lidocaine, etc Medications: • Avoid NSAIDS, ASA, St. John’s Wort, Various herbals that increase bleeding.

Obtaining Consent • Discussing side effects – Bruising, bleeding, over or under-correction, granuloma, sensation of filler at site, skin necrosis

• Alternatives • Types of Injectables • Alternative Clinicians- Derm/Plastic

• Consent to photography

Patient prep • Decision to use topical Anesthetic – Start 30 minutes at least prior to procedure

• Cleaning Skin with alcohol • Mirror for patient to assist in evaluation

Post Injection • Smoothing after injection – May not be required for HA due to smoothness – Can be done for all if you need to push filler to better result – May result in increased bruising.

• Warn about over correction appearance for 1-2 weeks – Real view (minus blood bruise) immediately after injection

Basic Injection Sites • Start with areas associated with most common injections and lower risks • Most common – Nasolabial folds – Marionette lines – Fine lines (peri-oral, Crow’s feet, forehead)

• More Advanced – Tear Trough, Cheek Augmentation, Pre-sulcus jowls

Nasolabial Folds • Use thicker products – Perlane, Juvederm Ultra Plus, Radiesse

• Threading technique more common, multiple close together – May use Puncture technique for upper triangle – 0.05cc with each pass

• Topical Anesthetic or products with lidocaine in it • Don’t underestimate amount to save $

Nasolabial Folds Before

After

Video on Nasolabial Folds: Hyluronic Acid and Ca Hydroxylapatite

Marionette Lines • Can use same products as for Nasolabial fold or for finer lines depending on volume to be used • Usually a cross hatch technique • Goal is to lift corner of the mouth and eliminate/soften the lines

Marionette lines with Radiesse Before

After

Finer lines • Products – HA such as Restylane Silk, Juvederm Ultra

• Technique – Serial puncture, threading with bent needle, – More superficial than larger lines

• Avoid blanching

What do you need to do to start? • Business Planning • Additional Costs • Advertising

Building the Business Plan • • • •

Why Should I even consider it? Do we have the patient base? What procedures would I like to perform? What product(s) should I buy and why?

Additional Costs • Malpractice – Usually not an issue for injectibles

• Advertising • Opportunity Costs • Personnel Costs

Advertising • • • • • •

Office ads Pamphlets Web sites Radio, TV Newspapers Lectures

Advertising: Promos

Marketing the practice • • • •

Current Patients New Patients Business Relationships Differentiating from others doing the procedure

Marketing to current practice • • • •

Data Analysis In-Office posters/pamphlets Dr. Buy In Direct mailing

Developing New patients • • • • •

Outside advertising Word of Mouth Patient referral discounts Other physicians Local paper articles

Resources • Sales representatives – Provide product, set up account, provide training via courses

• Training tapes – Aesthetic Video Source at www.videoshelf.com

• Books – Cosmetic Dermatology: Principles and Practice by Leslie S. Baumann : McGraw-Hill Professional; 2nd edition – Procedures in Cosmetic Dermatology Series: Soft Tissue Augmentation. by Jean Carruthers (Editor), Alastair Carruthers (Editor)

Resources • MedEsthetics Magazine – Free at medestheticsmagazine.com • Ho d, Jagdea J. Voluma: Asytematic review of clinical experience. J Drugs Dermatol. 2015;14(9): 934.

Practice Recommendations • Upon returning to your practice: – 1. Determine demographics for Filler type patients discussed. – 2. Contact Companies related to Filler products – 3. Schedule hands on training through companies, courses, or via colleagues already trained. – 4. Provide discounts to first few patients scheduled.

Contact information Donald Brideau, MD, MMM Chief Operating and Chief Medical Officer Inova Mount Vernon Hospital 2501 Parkers Lane, Alexandria VA 22306 Work Phone: 706-664-8597 Email: [email protected] Inova Family Medicine, Springfield Inova Medical Group,

Interested in More CME on this topic? aafp.org/fmx-procedural